Provider Demographics
NPI:1053055301
Name:BLANKENSHIP, JONATHAN CHARLES
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CHARLES
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:ALTAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95221-0456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95222-9607
Practice Address - Country:US
Practice Address - Phone:209-736-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37006101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health